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Lumbar Manipulation and Exercise in the Management of Anterior Knee Pain and Diminished Quadriceps Activation Following ACL Reconstruction: A Case Report.

Authors: Jayaseelan DJ, Courtney CA, Kecman M, Alcorn D

Quadriceps weakness is a common finding following knee injury or surgery, and can be associated with significant functional limitations. This weakness or muscle inhibition may be due to central inhibitory mechanisms, rather than local peripheral dysfunction. Lumbopelvic manipulation has been shown to effect efferent muscle output by altering nociceptive processing. The purpose of this case report is to describe the physical therapy management of anterior knee pain and chronic quadriceps weakness utilizing side-lying rotational lumbar thrust manipulation and therapeutic exercise for an individual eight months status-post ACL reconstruction.  In this case, a 20 year-old male presented to physical therapy eight months following anterior cruciate ligament (ACL) reconstruction of the left knee with primary complaints of residual anterior knee pain and quadriceps weakness. The subject was treated with a multimodal approach including side-lying rotational lumbar thrust manipulation in addition to therapeutic exercise.   The subject was seen in physical therapy for eight sessions over eight weeks. Lower Extremity Functional Scale (LEFS) scores improved from 58/80 to 72/80, quadriceps force, measured by hand-held dynamometry (HHD), was improved from 70.6 lbs to 93.5 lbs and the subject was able to return to pain free participation in recreational sports.  The authors concluded that therapeutic exercises can facilitate improved quadriceps strength, however, in cases where quadriceps weakness persists and there is concurrent pain, other interventions should be considered. In this case, lower quarter stabilization exercise and lumbar thrust manipulation was associated with improved functional outcomes in a subject with anterior knee pain and quadriceps weakness. Side-lying rotational lumbar thrust manipulation may be a beneficial adjunctive intervention to exercise in subjects with quadriceps weakness.

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